Liam Twomey (Wexford, Fine Gael) | Oireachtas source

I wish to make two points to Deputy Tom Fleming. When he is framing his reply to the patient to whom he referred, the Deputy should point out that only two weeks ago the Minister of State, Deputy Kathleen Lynch, announced the allocation of an extra €64 million in respect of the fair deal scheme. The provision of this money will ensure that people have access to exactly the same conditions which obtain at present. There is no change coming. Up to now, people were obliged to wait 16, 18 or 20 weeks to be accepted onto the scheme. With the investment of the additional €64 million, however, patients can now look forward to a shorter waiting period of between four to six weeks before they receive a reply regarding whether they have been accepted to the scheme. The person who wrote to Deputy Tom Fleming should rest assured that things are getting better, that there is not going to be any change and that there will be no increase in numbers. We have been remiss in terms of getting the message across on this matter.

I am the only Member of the House who remains a registered doctor and who is still in a position to write prescriptions. In that context, I disagree with what the NAGP said to Deputy Tom Fleming. The deal in respect of children under six years of age is good for patients, doctors and, in particular, hard-pressed parents. All the arguments thrown up in respect of this issue can be counterpointed by others. Every aspect of the health service requires further investment but the Government has made a decision and instigated a clear policy change. The latter is important because we are moving into a new era in the context of how GP services are provided. We are moving away from the existing acute system that was agreed with dispensary doctors in the 1940s. As Deputy Tom Fleming is aware, we are not going to revisit that system. Instead, we are going to move forward in terms of how our health care system works.

First, we are going to consider the position with regard to chronic care management. In that context, we can control an illness such as asthma to a fair degree. However, the impact of this condition is costing Irish patients millions of euro in lost earnings each year as a result of the fact that they cannot go to work. The most regrettable statistic is that which indicates that each week one person dies as a result of an asthma attack. Those deaths are preventable. We are putting in place a programme to allow us to begin looking after patients with asthma. There will also be for the first time ever in the area of primary care a new programme of chronic care in respect of the management of diabetes. Let us consider all the complications of diabetes. I refer to blindness, heart disease, kidney disease and vascular disease. People whose diabetes is not controlled can be obliged to have limbs amputated, can go blind and can die too soon.

We are making a start and saying we are going to change how things are done in the area of primary care. On that basis alone, I completely disagree with what the organisation to which Deputy Tom Fleming referred said to him. I am of the view that it is clearly missing the big picture in the context of the direction in which general practice is going. I completely support the Minister of State, Deputy Kathleen Lynch, and the Minister, Deputy Varadkar, in what they are doing. I also commend the Irish Medical Organisation. I must declare a vested interest in this regard in that I have been a member of the latter. The organisation is a progressive entity and it realises that the Bill represents a significant milestone on our journey to reform and modernise primary care. When we sort everything out, some 30,000 elderly people and 270,000 children under the age of six are going to benefit.

I am concerned with regard to the position of the primary care reimbursement scheme, PCRS, which is vital in the context of how the health service is going to work into the future. The PCRS was established in 2011 in order to centralise the distribution of medical cards. It receives a huge volume of applications and makes a correspondingly huge number of payments to service providers such as GPs, dentists and pharmacists. This is a massive and vital entity and we must ensure that it works for all those who avail of its services. For example, it must be made to work for medical card applicants. The application process can sometimes be burdensome. A person's application can be rejected on the basis of something simple or straightforward. In other instances, repeated requests for additional information can be made. The system is still too paper-based in nature and involves too many delays for patients. An issue also arises in respect of patients who fail to apply in time and who are left without medical cards, and the cover and protection these provide, for far too long. That is not even to mention the concerns that have been raised in the medical media with regard to what is happening with payments to doctors etc.

The PCRS is sometimes seen as an easy target. I accept that there is a need for some form of dispute resolution mechanism. More importantly, however, the PCRS must have the full trust and confidence of patients and service providers, namely, doctors, dentists and pharmacists. Politicians must also be able to rest assured that the scheme works. We do not need to be visited by patients informing us that they cannot obtain their medical cards as a result of how the PCRS operates. At present, we are discussing combating diabetes and dealing with asthma in young children. We are also concerned with the development and growth of such children. In the years to come, however, the primary care system is going to deal with every single known chronic disease or condition, including hypertension, high cholesterol, obesity and metabolic syndrome. We have been presented with a real vision as to how primary care is going to work in the future. The PCRS is central to ensuring that we can deliver everything we want for the people of Ireland. Deputy Ó Caoláin outlined how he wants this to be done but the important thing is that it will be done. Not only is the Government delivering what it has promised, it is also examining the system in order to ensure it can deliver for patients.

The Minister of State will be well aware of the Prospectus report on the PCRS. That report acknowledges the problems that exist within the organisation. We also acknowledge those problems and we are aware that the PCRS must be streamlined. We are going to work on this matter because we are aware that the PCRS is fundamental to what we are going to do in future. There is already a memorandum of understanding in place between the Irish Medical Organisation and the Minister, Deputy Varadkar, in the context of developing a brand new contract for general practitioners. That contract will not just relate to children under the age of six or the 36,000 people over 70 who are going to receive doctor visit cards, it will involve every single aspect of primary care. This is a massive undertaking and the Minister and the Irish Medical Organisation have committed to reporting back within one year in order to progress the issue. Both sides are driven in terms of finding a solution.

The people I know in the PCRS, the HSE and the Department of Health and the Ministers and doctors who were involved in the vital negotiations which took place all have a passion for this. They are not concerned with moaning or with identifying everything that is wrong. They are only interested in finding solutions. The Bill is about putting in place solutions. The new contract for general practitioners is going to make a huge difference. Most patients do not know that the proposed changes are coming and they are not yet aware of how they are going to be affected. That is because when one gets it right, no one notices. It is only when something goes wrong that people take note.

Massive changes are coming. Deputy Tom Fleming has seen evidence of this in his constituency of Kerry South in terms of the service provided by SouthDoc.

Without SouthDoc in Deputy Tom Fleming's constituency, he would be complaining morning, noon and night about the difficulty of attracting young doctors to work in County Kerry. We can attract young doctors because we are streamlining that service and investing in out-of-hour services. We will always hear about the problems, such as the difficulties in attracting doctors to isolated rural areas and deprived urban areas. The doctors who will benefit most from the contract we announced last week are those who are providing health care in deprived urban areas and isolated rural areas. Why is the Deputy opposite not calling for the contract to be put in place at the earliest opportunity given that it is going to provide GP services to the people they represent? It is easier to find something wrong in order to promote something that is not really happening. These are important changes and he should be supporting them.

I have no doubt that people who are passionate about what they are doing, including those within the HSE, are going to change the way we deliver out-of-hours services in the coming years. When these changes come about, the Members of this Parliament should discuss the issues arising for their constituents with an open mind instead of simply trying to get a dig at the incumbents. I may not be standing on this side of the House when the change finally happens. Deputy Tom Fleming and his colleagues may be standing in my place.

The technology now exists to allow a doctor to monitor a patient's heart or lung conditions even though they are separated by 50 miles. The doctor can diagnose the patient using information technology. We could be sending a paramedic instead of a doctor out in an ambulance. Doctors are becoming a scarce resource. Some 40% of GPs trained in this country are now in Australia, UK or Canada because doctors are a scarce resource in every English speaking country. If one needs care from SouthDoc or Caredoc on a weekend night, the doctor might be South African or Sudanese. For the last 30 years, hospital doctors were likely to come from India or Pakistan. We cannot fritter away these professionals. The Minister for Health made it clear to the IMO that the European working time directive will not work in this country unless all of us agree to do things differently. As I have pointed out on many occasions, my nurse carries out vaccinations, takes the bloods for my surgery, looks after warfarin patients and carries out 24 hour blood pressure monitoring. We do not get payment for any of those services but they are part of what we consider to constitute a proper GP service. GP practices which do not provide these services are paid the same as we are. Practices must be properly resourced to carry out this work.

It is recognised that better use could be made of information technology. We do not even know how many people in this country have diabetes or high blood pressure. We make estimates based on health surveys but accurate data are available in GP practices. We have to seek out that data. We used to send bloods to hospitals to be tested for warfarin, and waited for them to send us back the results. Such an approach gives rise to risks that a telephone call is not made or a blood test is not carried out. We now have an opportunity to test bloods in surgeries but the HSE must recognise that the doctors who carry out this work deserve some form of payment. They have to be reimbursed for the machines used to administer the tests, the test strips and the time consumed in monitoring the testing to ensure there are no mistakes. This is why protocols are needed to ensure we do things right. We are spending huge amounts of money on medication and community care services but we need to invest more money on the latter to allow people to stay at home. One hour of care per day can allow an elderly person to live in his or her own home. Since my father passed away, my mother took on a role as a care assistant in the community. Although she is 73 years old, she is still able to do that job because it allows her to interact with people and speak with them about their lives. It is a difficult service to deliver because it requires the right type of person. It is not a job for anybody and it is difficult in certain parts of the country to find suitable people. However, it is vital and the primary care division of the HSE must have a clear goal for its development.

We need policy objectives and clear thinking. When one considers what we are doing in respect of those under the age of six, the diabetes programme and the asthma programme, it is clear that we are also working behind the scenes in the HSE and with doctors and nurses to ensure these services work in practice. Tonight we are debating the issue of primary care for people aged over 70 years but we could be having similar discussions on ambulance services and mental health services, which have undergone a dramatic change in recent years. In my county of Wexford, we have closed St. Senan's inpatient hospital and put in place four community care teams for mental health, as well as a number of day hospitals. These changes have allowed us to reduce dramatically the numbers requiring admission by 40% or 50%. That means better care for patients. We should take the same approach to the acute hospital sector. Everybody knows we are amalgamating the three children's hospitals in Dublin but we should be equally visionary when it comes to providing other services.

It is not a question of cutting costs. We went through an awful era of reductions in health budgets which resulted in bad feelings and problems in our health services. However, not all of the problems arising in the acute hospital sector in the past six years were due to a lack of money. Many of them pertained to how services were administered and managed. If somebody calls him or herself a manager, he or she is responsible. Senior people in the HSE have an important role to play, and some of them are doing a very good job. I am always impressed by the level of commitment shown by people in the HSE to delivering services in a fair and equitable manner. They are easy to demonise. I was not a great fan of the decision to establish the HSE but it has developed a corporate structure that is finally beginning to work.

We should stop changing things around so much, because this creates confusion within the organisations we are dealing with. We need to bed down the hospital groups and the administrative pillars within the HSE and make them work to deliver for patients.

Great changes have been made and now that we have the budgets, it is time to move on with more reform and efficiency to deliver a better health service for people.

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